By Rabbi Dr. Aaron E. Glatt, MD
Boruch Hashem, we continue to gradually and successfully reopen NYS, Nassau County, and our local communities and neighborhoods, with Long Island scheduled to enter Phase III Wednesday June 24th. Unfortunately, this has not been the case everywhere in the country. Arizona, Florida, Oklahoma, Oregon and Texas all reported record increases in new cases – after recording all-time highs last week. Many cities with large Jewish populations, and 22 states overall are going in the wrong direction. It remains unknown why some regions see such startling rises in new COVID-19 cases, whereas others like us, are fortunate to continue with baseline lows. And even when occasional new cases are identified, it has fortunately not led to larger outbreaks.
I will iy”H discuss further expanding our “bubbles”, including how children’s groups and summer camps might impact those decisions, as well as discussing restarting public live non-virtual Torah learning on Motzei Shabbos at 9:45 pm in our usual zoom chat room, Meeting ID: 980 3243 6809; Password: 5TFRBM.
As there are many questions being asked on the chat, I will shorten my presentation and leave more time for Q & A following the talk. For those unable to log on, a live YouTube option will also be provided.
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What important new studies came out this week?
1) The “steroid study” showing decreased death rates in patients with COVID-19 was front page news in the lay press and was read by most people. But what did the study really show? As it is not yet published, I can only comment on what the study investigators themselves announced, which is not the way we usually obtain medical information. This study, called RECOVERY (Randomized Evaluation of COVid-19 thERapY) tested many potential COVID-19 treatments, including dexamethasone, a well-known steroid.
175 hospitals in the UK enrolled 2,104 patients to receive low-dose dexamethasone for ten days compared with 4,321 non-steroid treated otherwise similar patients. Among patients who did not get steroids, mortality was 41% in those requiring a ventilator; 25% in those requiring oxygen; and 13% among those not requiring any respiratory intervention. Dexamethasone reduced deaths by one-third in ventilated patients and by one fifth in patients receiving oxygen only. HOWEVER – there was no benefit among patients not requiring respiratory support.
Based on these results, 1 death would be prevented by treating ~ 8 ventilated patients or ~ 25 patients requiring oxygen alone. (Fortunately, treating with steroids is something we and many hospitals have already been doing for these very sick patients). No benefit would be received (and toxicity would occur) if healthier (i.e. not requiring oxygen) COVID-19 patients were started on steroids.
Bottom Line: Newly diagnosed patient with COVID-19 not requiring supplemental oxygen should NOT be taking steroids without evaluation by a physician; close monitoring of oxygen saturation is essential.
2) A very complex mathematical modeling study published in Nature Medicine from 32 locations in China, Italy, Japan, Singapore, Canada and South Korea provided crucial information regarding children, schools and summer camps. Susceptibility to infection in children under 20 was half that of adults over 20 years old. Clinical symptoms of COVID-19 manifested in only 21% of those aged 10 – 20 years, versus 69% in people over 70. Wow!
Therefore, interventions aimed at children might have a relatively small impact on reducing transmission, particularly if the transmissibility of asymptomatic infections is lower. These findings suggest that school closures – introduced in many countries as part of lockdowns aimed at controlling the coronavirus pandemic – are likely to have a limited impact on transmission of the disease. Countries (I would possibly add communities) with more young people may thus experience a lower risk of COVID-19 transmission.
3) An MMWR paper updated CDC surveillance data confirming that COVID-19 has more severe outcomes in older adults and those with underlying health conditions.
What is added by this report? As of May 30, 2020, the most common underlying health conditions among COVID-19 cases were cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%). Hospitalizations were six times higher and deaths 12 times higher among those with underlying conditions versus those without.
Hospitalizations and ICU admissions increased with age. Deaths were highest among persons aged ≥70 years, regardless of underlying conditions, and lowest among those aged ≤19 years.
What are the implications for public health practice? These findings highlight the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission. When people walk around as if COVID-19 is over, they are to a certain extent showing disregard for the health of the older at-risk individuals around them.
4) Final nail in the hydroxychloroquine (HCQ) coffin? The FDA retracted emergency use authorization for HCQ for Covid-19, and simultaneously warned of drug-drug interactions when paired with remdesivir. The FDA noted certain drugs may reduce the antiviral activity of remdesivir, potentially making the drug less effective. Drug-drug interaction trials of remdesivir and other medications have not been conducted in humans. Due to antagonism observed in vitro, concomitant use of remdesivir and HCQ is not recommended.
5) Does blood type make a difference with COVID-19?
A New England Journal of Medicine article supported an association between A, B O blood types and COVID-19 outcome based upon other genes that often go along with certain blood types. They detected a novel susceptibility locus at a chromosome 3p21.31 gene cluster and confirmed a potential involvement of the ABO blood-group system in Covid-19. What does this mean in English: Blood group specific analysis showed a slightly higher risk in blood group A than in other blood groups and a slightly protective effect in blood group O.
As an aside, there are severe shortages of blood products to give patients because community blood drives were closed for the past few months. If you are able to donate blood – please consider doing so at any NY Blood Center location or in upcoming community drives that will be opening up shortly.
When can Keilim Mikvaos reopen?
I think that with appropriate social distancing, plus routine handwashing after usage, keilim mikvaos can reopen safely.
What about resuming shiva visits?
At this point, I think this can be done safely too, outdoors, in a limited fashion, if the people sitting shiva feel comfortable from their own risk perspective in doing this. The Rabbonim of the community are working on a safe way to set up such visits.
Is there a concern for a woman to get pregnant during the COVID era?
As opposed to zika, which raised numerous halachic questions regarding birth control, pregnancy avoidance and even abortion shailos, there is NO evidence to suggest that we should revise regular general halachic decisions regarding pregnancy secondary to any COVID-19 concerns. We should im yertza Hashem continue to see numerous semachot in our communities – making shidduchim, engagements, weddings, and beautiful celebrations of healthy children being born without any hesitation – and continue life in this regard despite COVID-19!
I am receiving many emails which are often duplicative, so I have put together some FAQs, some of which are straight from the CDC with my slight modifications, and some specific for our community.
Should I go to minyan or go out shopping? I am at “higher risk” because of age or underlying illness…
This is one of the most commonly asked questions. My answer remains the same – no one should feel pressured to do anything they have concerns about. However, if the activity is safe (e.g. a minyan, even indoors, run properly with masks and distancing) then it is a personal choice if you wish to do this. The same thing applies to expanding the bubble – I cannot quantify these risks. Same with the “plane versus car” travel questions. There are too many variables. All I can recommend is to make the risk as low as possible and then decide if it is worth it to you to accept such an increased but low risk.
Should healthcare workers living with someone at higher COVID-19 risk take special precautions?
The CDC recommends no additional precautions are necessary in this setting, although some may choose to implement extra measures when arriving home, such as removing clothing worn during work. Healthcare workers and spouses CAN use the mikvah, CAN go to minyanim, CAN go out in public, etc.
When is someone infectious?
COVID-19 RNA may be detectable in the respiratory tract for weeks after illness; however, detection does not necessarily mean that infectious virus is present. Asymptomatic infection (detection of virus without ever developing symptoms) and pre-symptomatic infections (detection of virus prior to symptoms) occurs, but their role in transmission is not fully understood. Based on existing literature, the incubation period (the time from exposure to development of symptoms) ranges from 2–14 days.
Can people who recover from COVID-19 be re-infected?
The immune response, including duration of immunity, remains not fully understood. Patients are unlikely to be re-infected shortly after they recover, but it remains unknown for how long.
Should post-exposure prophylaxis be used for those exposed to COVID-19?
There is currently no FDA-approved prophylaxis for someone exposed to COVID-19. The exposed person MUST self-quarantine for 14 days. If the exposed individual previously had proven COVID-19 or has true antibodies to COVID-19, the CDC still suggests they follow full quarantine recommendations. However, my personal opinion is that very strict adherence to masking and social distancing without necessarily mandating full self-quarantine is also reasonable.
What does it mean if I have persistent detection of COVID-19 RNA after clinical recovery?
While most recovered persons no longer have detectable RNA, some have persistent positive nasopharyngeal swab tests. This may occur even after testing negative twice; later results can be positive again, and RNA can be detected for up to 6-8 weeks. This is probably just dead genetic material.
Am I contagious if I test persistently or recurrently positive?
It is very unlikely that such persons pose an infectious risk to others. Efforts to isolate live virus from upper respiratory tract specimens have been unsuccessful more than 10 days after illness onset. In addition, there is no evidence that clinically recovered persons with persistent or recurrent detection of viral RNA have transmitted COVID-19 to others.
One more time – what does the presence of antibody exactly mean?
The official CDC position, reiterated again this week, states that there is no firm evidence yet that the antibodies that develop in response to infection are protective. Even if protective, it’s not known what titers are associated with safety from reinfection. I again add however, that there is absolutely no evidence that it is not fully protective, and I do use antibodies as one factor when making decisions and recommendations in certain individual cases.
If an infected person has recovered, do they need a “test of cure”?
No. If symptoms have resolved or are resolving, and they have no fever for at least three days and are more than 14 days from the onset of symptoms, they can resume non-quarantine status.
If an infected person has recovered, do they need to wear a face covering in public?
Yes. It is recommended that almost all persons wear face coverings in public, which should cover the mouth and nose. The primary purpose is to limit transmission from infectious persons who may not have symptoms, or who have early or mild symptoms that they do not recognize. Masks may also offer some protection against exposure, provide reassurance to others in public, and act as a reminder to maintain social distancing. Face coverings should not be placed on children under age 2.
And finally, the most frequent FAQ I am asked – can I “bubble” with or visit so and so?
I am inundated with such questions and it is almost always impossible for me to quantify an answer. Ultimately it is a personal choice. Risk taking is something you must be willing to accept for yourself – I cannot tell you to do so. The best advice: The smaller the risk, plus the greater the necessity to take it – the more reasonable that choice becomes.
I hope that our current state of relative COVID-19 calm persists. May Hashem continue to shower kindness on those following appropriate masking and social distancing rules, and may no illness occur and spread in those not taking the fullest precautions.
Have a great Shabbos.